Knee Surgery, Sports Traumatology, Arthroscopy最新文献_第9页

Optimising outcomes in lateral unicompartmental knee arthroplasty: Analysing 25 years of registry data 优化外侧单腔膝关节置换术的结果：分析25年的登记数据。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-13 DOI: 10.1002/ksa.12785

Kristine Ifigenia Bunyoz, Martin Lindberg-Larsen, Kirill Gromov, Anders Troelsen

Purpose

Limited data and experience surround lateral unicompartmental knee arthroplasty (UKA), contributing to uncertainty regarding its broader application in clinical practice. To understand how to optimise lateral UKA outcomes, this study aimed to evaluate the implant survival of lateral UKA and compare it to total knee arthroplasty (TKA) using registry data.

Methods

Data were obtained from the Danish Knee Arthroplasty Registry, the Danish National Patient Registry and the Danish Civil Registration System. Between 1997 and 2022, all primary lateral UKAs (n = 538) and primary TKAs performed on valgus-aligned knees were included. Propensity score matching (1:4) matched patients by age, sex, weight, Charlson comorbidity index, year of surgery and hospital type. Survival analysis used the Fine-Gray subdistribution hazards model to account for competing risks.

Results

The 5-year cumulative revision risk was 10.1% for lateral UKA and 5.0% for TKA (1997–2022). For lateral UKA, this decreased from 25.0% (1997–2006) to 7.3% (2017–2022); TKA decreased from 4.6% to 3.7%. Surgery after 2011 and use of the fixed lateral Oxford (FLO) implant significantly reduced the risk of revision. Compared to TKA, the subdistribution hazard ratio for revision was 0.7 (95% confidence interval [CI] = 0.2–2.2) for the FLO implant and 3.4 (95% CI = 1.9–6.1) for other lateral UKAs in the period 2017–2022. No differences were found in 90-day readmissions or complications between lateral UKA and TKA, but the 2-year reoperation rate was significantly lower for lateral UKA in both periods.

Conclusion

Lateral UKA survival has evolved with improved understanding of knee compartment biomechanics, indications, surgical techniques and implant designs. Lateral UKA with the FLO implant showed lower or similar revision rates compared with TKA.

Level of Evidence

Level III.

目的：关于外侧单室膝关节置换术（UKA）的数据和经验有限，导致其在临床实践中的广泛应用存在不确定性。为了了解如何优化外侧UKA的结果，本研究旨在评估外侧UKA的植入物存活率，并使用注册数据将其与全膝关节置换术（TKA）进行比较。方法：数据来自丹麦膝关节置换术登记处、丹麦国家患者登记处和丹麦民事登记系统。在1997年至2022年期间，包括所有在外翻对准膝关节上进行的原发性外侧uka （n = 538）和原发性tka。倾向评分匹配（1:4）根据年龄、性别、体重、Charlson合并症指数、手术年份和医院类型进行匹配。生存分析使用Fine-Gray亚分布风险模型来解释竞争风险。结果：外侧UKA的5年累积翻修风险为10.1%，TKA的5年累积翻修风险为5.0%（1997-2022）。对于横向UKA，这一比例从25.0%（1997-2006年）下降到7.3%（2017-2022年）；TKA从4.6%下降到3.7%。2011年之后的手术和使用固定侧位牛津（FLO）种植体显著降低了翻修的风险。与TKA相比，2017-2022年期间，FLO植入物翻修的亚分布风险比为0.7(95%置信区间[CI] = 0.2-2.2)，其他侧位uka翻修的亚分布风险比为3.4 （95% CI = 1.9-6.1）。侧位UKA与TKA在90天再入院或并发症方面无差异，但两期的2年再手术率均明显低于侧位UKA。结论：随着对膝关节生物力学、适应症、手术技术和植入物设计的理解的提高，侧位UKA的生存率也在不断提高。与TKA相比，带FLO种植体的侧位UKA的翻修率更低或相似。证据等级：三级。

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引用次数: 0

No added value of the neutrophil-lymphocyte ratio and platelet count to mean platelet volume ratio over the traditional serum markers (erythrocyte sedimentation rate and C-reactive protein) in the diagnosis of periprosthetic joint infection 中性粒细胞淋巴细胞比（NLR）和血小板计数与平均血小板体积比（PC/MPV）对假体周围关节感染（PJI）的诊断没有传统血清标志物（ESR和CRP）的附加价值。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-13 DOI: 10.1002/ksa.12768

Mohammad Kamal Abdelnasser, Ayat Bakhet, Mahmoud Elagramy, Mohammed Anter Abdelhameed

<div> <section> <h3> Purpose</h3> <p>Several serum biomarkers have been used to aid in the diagnosis of periprosthetic joint infection (PJI) including platelet count/mean platelet volume ratio (PC/MPV) and neutrophil to lymphocyte ratio (NLR). The purpose of this study is to report the diagnostic performance of the serum markers NLR and PC/MPV in periprosthetic joint infection and to compare these markers with other already established serum biomarkers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and other synovial biomarkers as synovial white blood cell counts (WBCs), polymorphonuclear leucocyte percentage (PMN%), leucocyte esterase and synovial culture.</p> </section> <section> <h3> Methods</h3> <p>This is a single centre prospective cohort study in which all patients with painful hip or knee arthroplasty presented to our clinic, whether they underwent a revision surgery or not, were evaluated for eligibility. Out of 145 patients with painful hip or knee arthroplasty that were evaluated, 35 patients were excluded leaving 110 patients with eligible for this study. Blood samples were taken within a week before the revision surgery or aspiration to obtain the following parameters: ESR, CRP, WBCs, NLR, PC, MPV and PC/MPV. The modified Musculoskeletal Infection Society (MSIS) criteria were set as the gold standard test for diagnosis of per PJI in the study.</p> </section> <section> <h3> Results</h3> <p>According to the MSIS criteria, 48 of them were septic and 62 were aseptic. The diagnostic accuracy of the new serum markers was lower than that of the traditional markers. Receiver-operator characteristic (ROC) curve analysis for the NLR showed an area under the curve (AUC) of 0.556 with <i>p</i>-Value = 0.321, for the PC/MPV showed an AUC of 0.586 with <i>p</i>-Value = 0.129 while that for ESR showed an AUC of 0.688 with <i>p</i>-Value = 0.001 and that for CRP showed an AUC of 0.778 with <i>p</i>-Value < 0.001. To determine whether adding each of NLR and PC/MPV to the traditional serum markers (ESR + CRP) would increase the diagnostic performance of these markers or not, we compared the four models: (1) ESR + CRP, (2) ESR + CRP + NLR, (3) ESR + CRP + PC/MPV and (4) ESR + CRP + NLR + PC/MPV. There was no significant difference between the four models in AUC which shows that no added value of using the new serum markers.</p> </section> <section> <h3> Conclusion</h3> <p>Traditional serum markers (ESR and CRP) still have the best diagnostic performance in the diagnosis of PJI even when compared to the newer markers such as NLR and PC/MPV, which show limited added value either alone or when combined with ESR +

目的：几种血清生物标志物已被用于PJI的诊断，包括血小板计数/平均血小板体积比（PC/MPV）和中性粒细胞与淋巴细胞比（NLR）。本研究的目的是报告血清标志物NLR和PC/MPV在假体周围关节感染中的诊断性能，并将这些标志物与其他已建立的血清生物标志物如红细胞沉降率（ESR）、c反应蛋白（CRP）和其他滑膜生物标志物如滑膜白细胞计数（wbc）、多形核白细胞百分比（PMN%）、白细胞酯酶和滑膜培养进行比较。方法：这是一项单中心前瞻性队列研究，所有髋关节或膝关节置换术疼痛患者，无论是否接受翻修手术，都被评估为合格。在145例髋关节或膝关节置换术患者中，35例患者被排除，剩下110例患者符合本研究的条件。在翻修手术或抽吸前一周内采血，获得以下参数：ESR、CRP、wbc、NLR、PC、MPV和PC/MPV。本研究将改良的肌肉骨骼感染学会（MSIS）标准作为诊断假体周围关节感染（PJI）的金标准测试。结果：按照MSIS标准，48例脓毒症患者，62例无菌患者。新血清标志物的诊断准确率低于传统标志物。NLR的受试者-操作者特征曲线分析显示曲线下面积（AUC）为0.556，p值= 0.321，PC/MPV的AUC为0.586，p值= 0.129，ESR的AUC为0.688，p值= 0.001，CRP的AUC为0.778，p值为p值。传统的血清标志物（ESR和CRP）在PJI的诊断中仍然具有最好的诊断性能，即使与NLR和PC/MPV等较新的标志物相比，它们单独或与ESR + CRP联合使用的附加价值有限。证据等级：一级，诊断性研究。

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引用次数: 0

Functional alignment in total knee arthroplasty is an umbrella term—A call for better definition and reporting quality! 全膝关节置换术中的功能对齐是一个总括性术语——要求更好的定义和报告质量！

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-13 DOI: 10.1002/ksa.12774

Antonio Klasan, Dragan Jeremic, Thomas Neri, Thomas Jan Heyse, Michael T. Hirschmann

Purpose

Functional alignment (FA) aims to achieve a symmetric, rectangular extension gap and a rectangular or trapezoidal flexion gap, positioning the components in a manner that reduces the compromises to the soft tissue envelope. Because the FA surgeon can accomplish this goal with a multitude of adjustments to the components' position or soft tissue balance, the purpose of the present study was to analyze the possible paths for achieving FA.

Methods

Ten knees undergoing robotic total knee arthroplasty (TKA) were analyzed. Based on the intraoperatively acquired data, a macro was created to perform a post hoc analysis of the 10 possible paths to align a TKA functionally: (1) starting from mechanical alignment (MA) or kinematic alignment (KA), (2) preserving either the position of the femoral or tibial component and (3) with equal, 1 mm gaps or with increased 90° lateral flexion laxity.

Results

Ten different knee phenotypes were analyzed (Var-Neu-Neu 2x; Neu-Neu-Val; Val-Val-Val; Neu-Val-Neu; Var-Neu-Var 3x; Var-Var-Var; Var-Var-Val). On average, 3.5 different paths resulted in FA for each TKA (range: 0–8). Two TKAs (Val-Val-Val; Var-Var-Val) could not be functionally aligned using any of the ten evaluated paths. One TKA could be functionally aligned using eight different paths.

Conclusion

Functionally aligning a TKA can be achieved through multiple adjustments, resulting in various implant positions and soft tissue balances. To better understand the different combinations behind FA, a more detailed nomenclature is needed, including which initial alignment (MA or KA) was utilized, which component's position (femoral or tibial) was preserved, and whether a rectangular or trapezoidal flexion space was targeted.

Level of Evidence

Level IV, therapeutic study.

目的：功能对准（FA）旨在实现对称的矩形延伸间隙和矩形或梯形弯曲间隙，以减少对软组织包膜的损害的方式定位组件。由于FA外科医生可以通过对组件的位置或软组织平衡进行大量调整来实现这一目标，因此本研究的目的是分析实现FA的可能途径。方法：对10例人工全膝关节置换术（TKA）进行分析。根据术中获得的数据，创建了一个宏，对10种可能的TKA功能对齐路径进行事后分析：(1)从机械对齐（MA）或运动学对齐（KA）开始，(2)保留股骨或胫骨部件的位置，(3)相等的1mm间隙或增加90°侧屈松弛度。结果：分析了10种不同的膝关节表型(Var-Neu-Neu 2x；Neu-Neu-Val;Val-Val-Val;Neu-Val-Neu;Var-Neu-Var 3 x;Var-Var-Var;Var-Var-Val)。每个TKA平均有3.5个不同的路径导致FA（范围：0-8）。两个tka (Val-Val-Val；Var-Var-Val)无法使用十个评估路径中的任何一个进行功能对齐。一个TKA可以使用8条不同的路径进行功能对齐。结论：通过多次调整可以实现TKA的功能对准，从而实现不同的种植体位置和软组织平衡。为了更好地理解FA背后的不同组合，需要更详细的命名，包括使用哪种初始对准（MA或KA），保留哪个部件的位置（股骨或胫骨），以及是针对矩形还是梯形屈曲空间。证据等级：四级，治疗性研究。

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引用次数: 0

Restoration of the trochlear peaks is unnecessary with a kinematic alignment-optimized femoral component as under-stuffing results in equivalent or better patient-reported outcome scores 采用运动对齐优化的股骨假体无需修复滑车峰，因为填充后的结果与患者报告的结果相当或更好。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12777

Stephen M. Howell, Ahmed Zabiba, Patrick Sadoghi, Alexander J. Nedopil, Maury L. Hull

Purpose

Kinematic alignment (KA) total knee arthroplasty (TKA) aligns the femoral component to restore the pre-arthritic posterior joint line, potentially altering the heights of the medial and lateral trochlear peaks. It remains unclear whether the femoral component should be adjusted to correct deviations in peak height. This study assessed whether >2 mm of under- or over-stuffing in peak height negatively impacted patient-reported outcome (PRO) scores compared to restoration within ±2 mm.

Methods

The study included 115 KA TKAs performed with a KA-optimized femoral component featuring a trochlea with a lateral ridge opening that creates a 20° valgus trochlear groove and a flattened medial ridge, and PROs at a mean of 22 (12–28) months. The surgeon measured the height of the trochlear peaks on the anterior femoral resection.

Results

Peak under-stuffing >2 mm occurred medially in 66% and laterally in 43%. Over-stuffing >2 mm was too infrequent for statistical analysis. Compared to restoration within ±2 mm, medial under-stuffing resulted in a non-equivalent 6-point higher Forgotten Joint Score (FJS) (p = 0.1087) and equivalent but 9- and 3-point higher Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) (p < 0.0001) and Oxford Knee Score (OKS) (p = 0.0020). Lateral under-stuffing yielded equivalent but 6-, 12- and 3-point higher FJS (p = 0.0484), KOOS JR (p < 0.0001) and OKS (p < 0.0001).

Conclusion

The KA-optimized femoral component features a patient-specific trochlea that addresses anterior arthritic trochlear variations, which are reported to range from −24° varus to 30° valgus. One possible explanation for why >2 mm of under-stuffing leads to superior PROs is that reducing the peak height compensates for over-stuffing above the native trochlea caused by the prosthesis's proximal overreach, with a reported average of 17 mm.

Level of Evidence

Level III.

目的：运动学对齐（KA）全膝关节置换术（TKA）对齐股骨假体以恢复关节炎前的后关节线，可能改变内侧和外侧滑车峰的高度。目前尚不清楚是否应该调整股骨假体以纠正峰值高度的偏差。该研究评估了与±2mm的修复相比，峰值高度不足或过度填充>.2 mm是否会对患者报告的预后（PRO）评分产生负面影响。方法：该研究包括115例KA tka，采用KA优化的股骨假体，该假体具有滑车外侧脊开口，形成20°外翻滑车沟和平坦的内侧脊，平均为22（12-28）个月。外科医生在股骨前切除术时测量了滑车尖峰的高度。结果：填充物下垫峰（2 mm）中、外侧分别占66%和43%。2毫米的填充物太少，无法进行统计分析。与±2 mm内修复相比，内侧填充导致遗忘关节评分（FJS）提高6分（p = 0.1087），膝关节损伤和骨关节炎关节置换术结果评分（oos JR）提高9分和3分(p)。结论：ka优化的股骨假体具有患者特异性滑车，可解决前关节炎滑车变异，据报道范围为-24°内翻至30°外翻。一种可能的解释是，减少峰值高度可以补偿假体近端过伸引起的滑车上方的过度填充，据报道平均为17毫米。证据等级：三级。

{"title":"Restoration of the trochlear peaks is unnecessary with a kinematic alignment-optimized femoral component as under-stuffing results in equivalent or better patient-reported outcome scores","authors":"Stephen M. Howell, Ahmed Zabiba, Patrick Sadoghi, Alexander J. Nedopil, Maury L. Hull","doi":"10.1002/ksa.12777","DOIUrl":"10.1002/ksa.12777","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>Kinematic alignment (KA) total knee arthroplasty (TKA) aligns the femoral component to restore the pre-arthritic posterior joint line, potentially altering the heights of the medial and lateral trochlear peaks. It remains unclear whether the femoral component should be adjusted to correct deviations in peak height. This study assessed whether >2 mm of under- or over-stuffing in peak height negatively impacted patient-reported outcome (PRO) scores compared to restoration within ±2 mm.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>The study included 115 KA TKAs performed with a KA-optimized femoral component featuring a trochlea with a lateral ridge opening that creates a 20° valgus trochlear groove and a flattened medial ridge, and PROs at a mean of 22 (12–28) months. The surgeon measured the height of the trochlear peaks on the anterior femoral resection.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Peak under-stuffing >2 mm occurred medially in 66% and laterally in 43%. Over-stuffing >2 mm was too infrequent for statistical analysis. Compared to restoration within ±2 mm, medial under-stuffing resulted in a non-equivalent 6-point higher Forgotten Joint Score (FJS) (<i>p</i> = 0.1087) and equivalent but 9- and 3-point higher Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) (<i>p</i> < 0.0001) and Oxford Knee Score (OKS) (<i>p</i> = 0.0020). Lateral under-stuffing yielded equivalent but 6-, 12- and 3-point higher FJS (<i>p</i> = 0.0484), KOOS JR (<i>p</i> < 0.0001) and OKS (<i>p</i> < 0.0001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>The KA-optimized femoral component features a patient-specific trochlea that addresses anterior arthritic trochlear variations, which are reported to range from −24° varus to 30° valgus. One possible explanation for why >2 mm of under-stuffing leads to superior PROs is that reducing the peak height compensates for over-stuffing above the native trochlea caused by the prosthesis's proximal overreach, with a reported average of 17 mm.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Level of Evidence</h3>\u0000 \u0000 <p>Level III.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17880,"journal":{"name":"Knee Surgery, Sports Traumatology, Arthroscopy","volume":"33 12","pages":"4291-4302"},"PeriodicalIF":5.0,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://esskajournals.onlinelibrary.wiley.com/doi/epdf/10.1002/ksa.12777","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577571","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12753

Carl Christian Holkgaard Burvil, Karina Nørgaard Linde, Maiken Stilling, Torben Bæk Hansen, Jesper Dalsgaard, Søren Rytter, Daan Koppens, Emil Toft Petersen

Purpose

To assess the influence of a higher constraint medial congruent (MC) versus a cruciate retaining (CR) (gold standard) polyethylene insert on the migration of cemented tibial and femoral components of the Persona Total Knee System. High-constraint inserts may increase forces on components and potentially affect implant migration and long-term fixation.

Methods

A cohort of 66 patients with primary knee osteoarthritis received a cemented Persona total knee arthroplasty and were randomised to either an MC or a CR polyethylene insert. Tibial and femoral component migration was assessed using static radiostereometric analysis, with the first stereo-radiograph taken supine on the first postoperative day (baseline) and again at 3-, 12-, and 24-month follow-up. Tibial and femoral component migration was evaluated in six degrees of freedom and as maximum total point motion (MTPM).

Results

At the 12-month follow-up, the mean difference in tibial component MTPM was 0.04 mm (95% confidence interval [CI]: −0.21 to 0.28). The mean MTPM was 0.81 mm (95% CI: 0.64–0.99) in the MC group and 0.85 mm (95% CI: 0.68–1.03) in the CR group. Signed migrations were similar for the MC and the CR group throughout 24 months of follow-up (p > 0.09). At the 12-month follow-up, the mean difference in femoral component MTPM was 0.18 mm (95% CI: −0.17 to 0.53). The mean MTPM was 1.08 mm (95% CI: 0.83–1.32) in the MC group and 1.26 mm (95% CI: 1.01–1.51) in the CR group. The femoral components with MC insert had 0.18 mm (95% CI: 0.03–0.32) and 0.20 mm (95% CI: 0.01–0.39) more lateral migration at 3- and 12-month follow-up, respectively. At the 24-month follow-up, there was no statistically significant differences in migration for either translations, rotations or MTPM.

Conclusions

Both tibial and femoral components had similar and acceptable fixation regardless of the type of polyethylene insert.

Level of Evidence

Level I.

目的：评估高约束内侧一致性（MC）与十字保留（CR）（金标准）聚乙烯假体对假面全膝关节系统骨水泥胫骨和股骨假体迁移的影响。高约束的植入物可能会增加对构件的作用力，并可能影响植入物的迁移和长期固定。方法：66例原发性膝骨关节炎患者接受骨水泥假人全膝关节置换术，随机分为MC或CR聚乙烯植入物组。使用静态放射立体分析评估胫骨和股骨假体的迁移，在术后第一天（基线）第一次仰卧位立体x线片，并在3个月、12个月和24个月的随访中再次拍摄。胫骨和股骨假体的移动以6个自由度和最大总点运动（MTPM）进行评估。结果：在12个月的随访中，胫骨成分MTPM的平均差异为0.04 mm（95%可信区间[CI]: -0.21至0.28）。MC组平均MTPM为0.81 mm (95% CI: 0.64-0.99)， CR组平均MTPM为0.85 mm （95% CI: 0.68-1.03）。在24个月的随访中，MC组和CR组的签名迁移相似（p < 0.09）。在12个月的随访中，股骨成分MTPM的平均差异为0.18 mm （95% CI: -0.17至0.53）。MC组平均MTPM为1.08 mm (95% CI: 0.83-1.32)， CR组平均MTPM为1.26 mm （95% CI: 1.01-1.51）。在3个月和12个月的随访中，带MC植入物的股骨假体的外侧偏移量分别增加了0.18 mm （95% CI: 0.03-0.32）和0.20 mm （95% CI: 0.01-0.39）。在24个月的随访中，无论是平移、旋转还是MTPM，在迁移方面都没有统计学上的显著差异。结论：无论何种聚乙烯内固定物，胫骨和股骨假体均具有相似且可接受的固定。证据等级：一级。

{"title":"Similar fixation of total knee arthroplasty components with medial congruent and cruciate retaining polyethylene inserts. A randomised double-blinded controlled radiostereometry trial with 24 months of follow-up","authors":"Carl Christian Holkgaard Burvil, Karina Nørgaard Linde, Maiken Stilling, Torben Bæk Hansen, Jesper Dalsgaard, Søren Rytter, Daan Koppens, Emil Toft Petersen","doi":"10.1002/ksa.12753","DOIUrl":"10.1002/ksa.12753","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>To assess the influence of a higher constraint medial congruent (MC) versus a cruciate retaining (CR) (gold standard) polyethylene insert on the migration of cemented tibial and femoral components of the Persona Total Knee System. High-constraint inserts may increase forces on components and potentially affect implant migration and long-term fixation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A cohort of 66 patients with primary knee osteoarthritis received a cemented Persona total knee arthroplasty and were randomised to either an MC or a CR polyethylene insert. Tibial and femoral component migration was assessed using static radiostereometric analysis, with the first stereo-radiograph taken supine on the first postoperative day (baseline) and again at 3-, 12-, and 24-month follow-up. Tibial and femoral component migration was evaluated in six degrees of freedom and as maximum total point motion (MTPM).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>At the 12-month follow-up, the mean difference in tibial component MTPM was 0.04 mm (95% confidence interval [CI]: −0.21 to 0.28). The mean MTPM was 0.81 mm (95% CI: 0.64–0.99) in the MC group and 0.85 mm (95% CI: 0.68–1.03) in the CR group. Signed migrations were similar for the MC and the CR group throughout 24 months of follow-up (<i>p</i> > 0.09). At the 12-month follow-up, the mean difference in femoral component MTPM was 0.18 mm (95% CI: −0.17 to 0.53). The mean MTPM was 1.08 mm (95% CI: 0.83–1.32) in the MC group and 1.26 mm (95% CI: 1.01–1.51) in the CR group. The femoral components with MC insert had 0.18 mm (95% CI: 0.03–0.32) and 0.20 mm (95% CI: 0.01–0.39) more lateral migration at 3- and 12-month follow-up, respectively. At the 24-month follow-up, there was no statistically significant differences in migration for either translations, rotations or MTPM.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Both tibial and femoral components had similar and acceptable fixation regardless of the type of polyethylene insert.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Level of Evidence</h3>\u0000 \u0000 <p>Level I.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17880,"journal":{"name":"Knee Surgery, Sports Traumatology, Arthroscopy","volume":"33 11","pages":"3840-3852"},"PeriodicalIF":5.0,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://esskajournals.onlinelibrary.wiley.com/doi/epdf/10.1002/ksa.12753","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577605","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Functional alignment in robotic total knee arthroplasty achieves comparable outcomes in varus and valgus knees despite distinct intraoperative strategies: Analysis of 355 consecutive cases 尽管术中策略不同，但机器人全膝关节置换术中的功能对齐在膝内翻和外翻中取得了相当的结果：分析355个连续病例。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12764

Christos Koutserimpas, Clemente Caria, Pietro Gregori, Luca Andriollo, Elvire Servien, Cécile Batailler, Sébastien Lustig

Purpose

Functional alignment (FA) optimises implant positioning based on patient-specific anatomy, but data on intraoperative adjustments in varus and valgus knees remain limited. This study evaluates the impact of preoperative coronal alignment on implant positioning, bone resections, functional outcomes, and revision rates in robotic-assisted total knee arthroplasty (TKA) under FA principles.

Methods

A retrospective analysis of 355 robotic-assisted TKAs performed with FA was conducted. Patients were classified as varus (n = 294, HKA < 180°) or valgus (n = 61, HKA ≥ 180°). Intraoperative implant positioning, bone resections, and alignment parameters were recorded. Functional outcomes were assessed using the Knee Society Scores, Forgotten Joint Score, and Kujala score. Implant survivorship was analysed using the Kaplan–Meier method.

Results

Varus knees required greater tibial varus positioning (3.5° varus [interquartile range [IQR] 2–5] vs. 1° varus [IQR 0–2.5], p < 0.0001), while valgus knees required increased femoral valgus positioning (1.5° [IQR 0.38–2.5] vs. 0.7° [IQR −0.5 to 1.83], p = 0.0004). Bone resections also differed significantly between groups. Specifically, the valgus group had lower lateral tibial (p = 0.0001), distal lateral (p < 0.0001), and posterior lateral femoral resections (p < 0.0001), but higher distal medial femoral resections (p = 0.04). Postoperative functional outcomes were comparable across groups. Survival rates were 98.64% (varus) and 98.36% (valgus) (p = 0.86), with a hazard ratio of 1.23 (95% CI: 0.12–12.57) for valgus knees.

Conclusion

This study systematically evaluates intraoperative modifications in FA-based robotic TKA for varus and valgus knees. Despite distinct balancing strategies, both groups achieved comparable outcomes and implant survivorship.

Level of Evidence

Level III.

目的：功能对准（FA）基于患者特定解剖结构优化植入物定位，但术中膝关节内翻和外翻调整的数据仍然有限。本研究评估了在FA原则下机器人辅助全膝关节置换术（TKA）中术前冠状面对齐对植入物定位、骨切除、功能结果和翻修率的影响。方法：回顾性分析355例机器人辅助全膝关节置换术。结果：膝关节内翻需要更大的胫骨内翻定位(3.5°内翻[四分位范围[IQR] 2-5] vs. 1°内翻[IQR 0-2.5]， p结论：本研究系统地评估了基于fa的机器人TKA术中对膝关节内翻和外翻的修改。尽管有不同的平衡策略，但两组的结果和种植体存活率相当。证据等级：三级。

{"title":"Functional alignment in robotic total knee arthroplasty achieves comparable outcomes in varus and valgus knees despite distinct intraoperative strategies: Analysis of 355 consecutive cases","authors":"Christos Koutserimpas, Clemente Caria, Pietro Gregori, Luca Andriollo, Elvire Servien, Cécile Batailler, Sébastien Lustig","doi":"10.1002/ksa.12764","DOIUrl":"10.1002/ksa.12764","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Purpose</h3>\u0000 \u0000 <p>Functional alignment (FA) optimises implant positioning based on patient-specific anatomy, but data on intraoperative adjustments in varus and valgus knees remain limited. This study evaluates the impact of preoperative coronal alignment on implant positioning, bone resections, functional outcomes, and revision rates in robotic-assisted total knee arthroplasty (TKA) under FA principles.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A retrospective analysis of 355 robotic-assisted TKAs performed with FA was conducted. Patients were classified as varus (<i>n</i> = 294, HKA < 180°) or valgus (<i>n</i> = 61, HKA ≥ 180°). Intraoperative implant positioning, bone resections, and alignment parameters were recorded. Functional outcomes were assessed using the Knee Society Scores, Forgotten Joint Score, and Kujala score. Implant survivorship was analysed using the Kaplan–Meier method.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Varus knees required greater tibial varus positioning (3.5° varus [interquartile range [IQR] 2–5] vs. 1° varus [IQR 0–2.5], <i>p</i> < 0.0001), while valgus knees required increased femoral valgus positioning (1.5° [IQR 0.38–2.5] vs. 0.7° [IQR −0.5 to 1.83], <i>p</i> = 0.0004). Bone resections also differed significantly between groups. Specifically, the valgus group had lower lateral tibial (<i>p</i> = 0.0001), distal lateral (<i>p</i> < 0.0001), and posterior lateral femoral resections (<i>p</i> < 0.0001), but higher distal medial femoral resections (<i>p</i> = 0.04). Postoperative functional outcomes were comparable across groups. Survival rates were 98.64% (varus) and 98.36% (valgus) (<i>p</i> = 0.86), with a hazard ratio of 1.23 (95% CI: 0.12–12.57) for valgus knees.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>This study systematically evaluates intraoperative modifications in FA-based robotic TKA for varus and valgus knees. Despite distinct balancing strategies, both groups achieved comparable outcomes and implant survivorship.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Level of Evidence</h3>\u0000 \u0000 <p>Level III.</p>\u0000 </section>\u0000 </div>","PeriodicalId":17880,"journal":{"name":"Knee Surgery, Sports Traumatology, Arthroscopy","volume":"33 11","pages":"3925-3934"},"PeriodicalIF":5.0,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://esskajournals.onlinelibrary.wiley.com/doi/epdf/10.1002/ksa.12764","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577564","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Robotic anatomo-functional alignment total knee arthroplasty accurately resurfaces the distal femur and preserves joint line obliquity: A prospective 3D modelling study 机器人解剖功能对齐全膝关节置换术准确地重塑股骨远端并保持关节线倾角：一项前瞻性3D建模研究。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12772

Santiago Claudel, Matthieu Ollivier, Maxime Fabre-Aubrespy, Julien Druel, Jean-Louis Milan, Thomas Valerio, Sébastien Parratte, Jean-Noël Argenson, Christophe Jacquet

Purpose

This study aims to evaluate the ability of a personalised robotic total knee arthroplasty (TKA) to accurately resurface the distal femur, maintain the native joint line obliquity (JLO), and optimise knee balancing, as measured on dedicated radiographs, with intraoperative measurement and CT scan 3D reconstruction.

Methods

In this prospective study, 100 patients undergoing primary personalized robotic TKA were included using an anatomo-functional alignment. The ability of this technique to resurface the distal femur was assessed using CT scans by comparing 3D models of each patient pre- and postoperatively. Frontal alignment and JLO were compared on full-length radiographs pre- and postoperatively. The evolution of knee laxity was measured intraoperatively for each patient before and after TKA.

Results

The average difference between the distal femur articular surface before and after TKA was 2.27 mm. The JLO was preserved in 91% of cases (p < 0.05). The gap width target (2 ± 1 mm: medial and lateral femorotibial gap in extension, as well as the medial femorotibial gap in flexion) was achieved among 78% of the patients with varus deformity and 69% of patients with valgus deformity.

Conclusion

The anatomo-functional alignment during TKA implantation, as described in this study, allows for resurfacing of the distal femur with millimetre precision, and the preservation of joint line orientation in most cases using robotic assistance. It also enables to restore a functionally optimal ligament tension both in extension and in flexion.

Level of Evidence

Level III.

目的：本研究旨在评估个性化机器人全膝关节置换术（TKA）的能力，通过术中测量和CT扫描3D重建，通过专用x线片测量，准确地重新表面股骨远端，保持关节线倾角（JLO），并优化膝关节平衡。方法：在这项前瞻性研究中，使用解剖功能校准纳入了100名接受初次个性化机器人TKA的患者。通过比较每位患者术前和术后的3D模型，通过CT扫描评估该技术对股骨远端表面重建的能力。在术前和术后的全长x线片上比较额位对齐和JLO。术中测量每位患者TKA前后膝关节松弛程度的变化。结果：TKA前后股骨远端关节面平均差为2.27 mm。在91%的病例中，JLO得以保存(p结论：本研究中描述的TKA植入期间的解剖功能对齐，允许以毫米精度重新铺设股骨远端，并且在大多数情况下使用机器人辅助保留关节线方向。它还可以恢复功能上最优的韧带张力在伸展和屈曲。证据等级：三级。

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引用次数: 0

Total knee replacement designs have differing stability under novel robotic testing method in vitro 在新的机器人体外测试方法下，全膝关节置换术设计具有不同的稳定性。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12761

Sander R. Holthof, Shuntaro Nejima, Mick Rock, Richard Jan vanArkel, Angela Brivio, David Barrett, Andrew A. Amis

<div> <section> <h3> Purpose</h3> <p>This study implemented a novel robotic test method to quantify the effect of three distinct total knee arthroplasty (TKA) designs on knee kinematics and stability. It was hypothesised that the implant geometries would affect stability and rollback, with differences between the native and replaced knees, as well as between implant designs.</p> </section> <section> <h3> Methods</h3> <p>Eight fresh-frozen cadaveric knees were tested across the arc of flexion-extension under 710 N compressive load, combined with either no anterior-posterior (AP) tibial force, 90 N anterior or 90 N posterior drawer force using a robotic actuator. The same testing protocol was used post-TKA using three distinct implant designs (gradually reducing femoral condylar radius medially stabilised, multi-radius medially conforming and single-radius symmetrical), matched to the same bone cuts. Laxity and rollback were analysed using statistical parametric mapping and implant designs were compared to the intact knee and each other.</p> </section> <section> <h3> Results</h3> <p>No significant differences in AP laxity were found between the intact knee (4.7 ± 0.7 mm), gradually reducing radius (6.3 ± 1.3 mm) and multi-radius designs (5.7 ± 1.1 mm). The single-radius implant showed significantly larger average AP laxity envelope (11.6 ± 2.3 mm) than the intact knee, the multi-radius design and the gradually reducing radius design and was more variable between knees. The rollback among the intact knee and TKAs were not significantly different: gradual radius 81% of native, multi-radius 85% and single-radius 90%.</p> </section> <section> <h3> Conclusions</h3> <p>Significant differences of AP laxity were found between the pre- and post TKA knee and between implant designs. Rollback did not differ significantly. Implanted knee behaviour also showed differences of sensitivity to cadaveric specimen and implantation variation among the prosthesis designs.</p> </section> <section> <h3> Clinical relevance</h3> <p>Instability post-TKA remains an issue for good patient outcomes. Robotic testing of implanted knees shows the effects of implant design on knee stability and motion, potentially improving outcomes by providing the surgeon with objective data on which to base their choice of TKA.</p> </section> <section> <h3> Level of Evidence</h3> <p>N/A. Controll

目的：本研究实施了一种新的机器人测试方法来量化三种不同的全膝关节置换术（TKA）设计对膝关节运动学和稳定性的影响。我们假设假体的几何形状会影响膝关节的稳定性和回退，这与天然膝关节和置换膝关节之间的差异以及假体设计之间的差异有关。方法：在710 N压缩载荷下，使用机器人驱动器测试8个新鲜冷冻的尸体膝盖在弯曲-伸展弧线上的弯曲-伸展，并结合无前后胫骨力（AP）， 90 N前或90 N后抽屉力。tka后使用相同的测试方案，使用三种不同的植入物设计（逐渐缩小股骨髁桡骨内侧稳定，多桡骨内侧符合和单桡骨对称），与相同的骨切口相匹配。使用统计参数映射分析松弛和回滚，并将假体设计与完整膝关节进行比较。结果：完整膝关节（4.7±0.7 mm）、逐渐减小桡骨（6.3±1.3 mm）和多桡骨设计（5.7±1.1 mm）的AP松弛度无显著差异。单桡骨植入物的AP松弛包膜（11.6±2.3 mm）明显大于完整膝关节、多桡骨植入物和逐渐减小的桡骨植入物，且不同膝关节间的差异更大。完整膝关节和tka的回退无显著差异：原生膝关节的渐变半径为81%，多半径为85%，单半径为90%。结论：TKA前后膝关节以及不同的假体设计之间的AP松弛度存在显著差异。回滚无显著差异。植入膝关节的行为也表现出对尸体标本的敏感性差异和不同假体设计的植入差异。临床相关性：tka后的不稳定性仍然是患者预后良好的一个问题。植入膝关节的机器人测试显示了植入物设计对膝关节稳定性和运动的影响，通过为外科医生提供选择TKA的客观数据，潜在地改善了结果。证据水平：实验室对照研究。

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引用次数: 0

The metaverse in orthopaedics: Virtual, augmented and mixed reality for advancing surgical training, arthroscopy, arthroplasty and rehabilitation 整形外科的虚拟、增强和混合现实：用于推进外科训练、关节镜检查、关节成形术和康复。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12723

Mahmut Enes Kayaalp, Efstathios Konstantinou, Bedri Karaismailoglu, Gian Andrea Lucidi, Mehmet Kaymakoglu, Romed Vieider, Joseph D. Giusto, Jumpei Inoue, Michael T. Hirschmann

Purpose

The metaverse and extended reality (XR), which includes augmented reality (AR), virtual reality (VR) and mixed reality (MR), are transforming orthopaedic surgery by enhancing training, procedural accuracy and rehabilitation. However, a literature review of these new virtual tools is lacking. The purpose of this narrative review is to summarise available evidence about the metaverse and discuss current and future clinical applications.

Methods

A narrative review of the current literature was performed for studies evaluating XR tools and their respective clinical and educational utility. Studies from all orthopaedic subspecialties were eligible for inclusion. The XR tools evaluated in each study were categorised according to the reality spectrum and future research or clinical applications were discussed.

Results

XR is a technological spectrum that includes AR, VR and MR to create immersive and interactive surgical training environments. VR-based simulators may improve surgical education by allowing trainees to refine their skills in a risk-free setting. AR may enhance intraoperative guidance and has been studied within orthopaedics to improve implant positioning accuracy and reduce complications in procedures including arthroscopy and total joint arthroplasty. In rehabilitation, AR and VR have been implemented to facilitate patient engagement and adherence, promoting functional recovery through gamified therapy and remote telerehabilitation.

Conclusions

There has been a paradigm shift in orthopaedic care in which digital tools are integrated with patient care to optimise patient outcomes. However, challenges to the widespread implementation of promising XR technology include high costs, steep learning curves and limited clinical validation. Ethical concerns, including data security and patient privacy, further complicate its use in clinical settings. Future research must focus on cost-effectiveness, standardisation and improving accessibility to ensure seamless integration into clinical practice.

Level of Evidence

Level V.

目的：包括增强现实（AR）、虚拟现实（VR）和混合现实（MR）在内的虚拟现实和扩展现实（XR）正在通过增强训练、程序准确性和康复来改变骨科手术。然而，缺乏对这些新的虚拟工具的文献综述。这篇叙述性综述的目的是总结关于元宇宙的现有证据，并讨论当前和未来的临床应用。方法：对当前文献进行叙述性回顾，以评估XR工具及其各自的临床和教育效用。所有骨科亚专科的研究均符合纳入条件。每项研究中评估的XR工具都根据现实谱进行了分类，并讨论了未来的研究或临床应用。结果：XR是一种包括AR， VR和MR的技术谱，用于创建沉浸式和交互式外科培训环境。基于vr的模拟器可以通过允许受训者在无风险的环境中完善他们的技能来改善外科教育。AR可以增强术中引导，并在骨科中进行了研究，以提高植入物定位的准确性，减少关节镜和全关节置换术等手术中的并发症。在康复方面，AR和VR已被实施，以促进患者参与和依从性，通过游戏化治疗和远程远程康复促进功能恢复。结论：骨科护理已经发生了范式转变，其中数字工具与患者护理相结合，以优化患者结果。然而，广泛实施有前景的XR技术面临的挑战包括高成本、陡峭的学习曲线和有限的临床验证。伦理问题，包括数据安全和患者隐私，使其在临床环境中的使用进一步复杂化。未来的研究必须关注成本效益、标准化和改善可及性，以确保无缝整合到临床实践中。证据等级：V级。

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引用次数: 0

Older age and a non-sporting injury mechanism are associated with re-injury and the need for revision surgery over a minimum 2-year follow-up following proximal hamstring tendon repair 年龄较大和非运动损伤机制与再次损伤相关，需要在近端腘绳肌腱修复后至少2年的随访中进行翻修手术。

IF 5 2区医学 Q1 ORTHOPEDICS

Knee Surgery, Sports Traumatology, Arthroscopy

Pub Date : 2025-07-07 DOI: 10.1002/ksa.12767

Jay R. Ebert, Peter K. Edwards, Elias Ammann, Adam Farrier, Lorcan Gavin, Method Kabelitz, Ross Radic, Antony Liddell, Peter Annear

Purpose

To investigate revision rates and factors associated with the need for revision following proximal hamstring tendon repair.

Methods

This study included 243 patients who underwent proximal hamstring tendon repair due to an acute (n = 176) or chronic (n = 67) tear. Complications, re-injuries and re-operations were reviewed. Risk factor analysis for re-rupture within 2 years of surgery was conducted using Cox proportional hazards regression, with variables including age, body mass index (BMI), sex, mechanism of injury (sport-related or other), time from injury to surgery and comorbidities including hypertension, hypercholesterolaemia and Type 2 diabetes. Receiver operating characteristic analysis explored time-to-surgery thresholds in relation to revision.

Results

Overall, 19 (10.8%) of the acute cohort and 11 (16.4%) of the chronic cohort underwent revision surgery due to re-tearing and recurrence of symptoms. In the acute cohort, an increased risk of re-injury was associated with a non-sporting (versus sporting) injury (hazard ratio [HR] = 3.38; 95% confidence interval [CI], 1.10–10.39; p = 0.033) and an older age (HR = 1.04 per year; 95% CI, 1.00–1.08; p = 0.031). In the chronic cohort, there were no significant associations between age, BMI, sex or comorbidities, with revision surgery. The optimal threshold for surgery for acute repairs was 30.5 days.

Conclusions

A 10.8% and 16.4% revision rate was observed over a minimum 2-year follow-up following proximal hamstring repair for acute and chronic tears, respectively. For chronic tears, no variables were associated with the need for revision. However, older age and non-sporting injury were associated with a higher risk of re-injury in the acute cohort.

Level of Evidence

Level IV, retrospective case series.

目的：探讨近端腘绳肌腱修复后翻修率及与翻修需求相关的因素。方法：本研究纳入243例因急性（176例）或慢性（67例）撕裂而行近端腘绳肌腱修复术的患者。回顾了并发症、再损伤和再手术。采用Cox比例风险回归分析手术2年内再次破裂的危险因素，变量包括年龄、体重指数（BMI）、性别、损伤机制（运动相关或其他）、损伤至手术时间以及合并症包括高血压、高胆固醇血症和2型糖尿病。接受者操作特征分析探讨了与翻修相关的手术时间阈值。结果：总体而言，19例（10.8%）急性队列和11例（16.4%）慢性队列因再撕裂和症状复发接受翻修手术。在急性队列中，再次损伤的风险增加与非运动损伤（相对于运动损伤）相关(风险比[HR] = 3.38；95%置信区间[CI]， 1.10-10.39；p = 0.033)和年龄较大(HR = 1.04 /年；95% ci, 1.00-1.08；p = 0.031)。在慢性队列中，年龄、BMI、性别或合并症与翻修手术之间没有显著关联。急性修复的最佳手术阈值为30.5天。结论：在至少2年的随访中，近端腘绳肌修复急性和慢性撕裂的修复率分别为10.8%和16.4%。对于慢性撕裂，没有变量与翻修的需要相关。然而，在急性队列中，年龄较大和非运动损伤与更高的再损伤风险相关。证据级别：四级，回顾性病例系列。

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引用次数: 0